S. Weir (Silas Weir) Mitchell.

Lectures on diseases of the nervous system, especially in women online

. (page 1 of 21)
Online LibraryS. Weir (Silas Weir) MitchellLectures on diseases of the nervous system, especially in women → online text (page 1 of 21)
Font size
QR-code for this ebook


Boston Medical Library
in the Francis A. Countway
Library of Medicine -Boston



I rv./



/ t ! -



X y



U - "



CX-ov-K ^ /



'riL



Cx^'



Digitized by the Internet Archive

in 2010 with funding from

Open Knowledge Commons and Harvard Medical School



http://www.archive.org/details/lecturesondiseasOOmitc



LECTURES



DISEASES OF THE NERVOUS SYSTEM,



ESPECIALLY IN WOMEN.



BY



S. WEIR MITCHELL, M.D.



'5



MEMBER OP THE NATIONAL ACADEMY OF SCIENCES;
PHYSICIAN TO THE ORTHOP-(EDIC HOSPITAL, AND INFIRMARY FOR DISEASES OF THE

NERVOUS SYSTEM ;

VICE-PRESIDENT OP THE PHILADELPHIA COLLEGE OF PHYSICIANS;

MEMBER OP THE NEW YORK ACADEMY OF MEDICINE J

HONORARY CORRESPONDING MEMBER OP THE BRITISH MEDICAL ASSOCIATION ;

HONORARY FELLOW OF THE LONDON MEDICAL SOCIETY;

FOREIGN ASSOCIATE OP THE ROYAL MEDICAL SOCIETY OF NORWAY;

AUTHOR OF A TREATISE ON INJURIES OF NERVES, ETC. ETC.

SECOND EmTION", KEYISED AND ENLARGED,

WITH FIVE PLATES.




PHILADELPHIA:

LEA BROTHERS & CO.
1885.



Entered according to the Act of Congress, in the year 1885, by

LEA BROTHERS & CO.,
in the Office of the Librarian of Congress. All rights reserved.



DORNAN, PRINTER



DEDICATED TO



J. HUGHLINGS-JACKSON, M.D., F.R.S.



WITH WARM PERSONAL REGARD,



IN GRATEFUL ACKNOWLEDGMENT



HIS SERVICES TO



THE SCIENCE OF MEDICINE.



PREFACE TO SECOND EDITION.



The book has been long out of print, but only
of late have I found time to prepare a second
edition.

I have altered considerably some of the
early lectures, and have added others on the
difficulties of diagnosis in hysterical diseases of
joints, on the relations of hysteria to organic
disease of the spine, and on hysterical disorders
of the rectum.



PREFACE TO FIRST EDITION.



The lectures which compose this volume deal
chiefly with some of the rarer maladies, or forms
of maladies, of women. Many of them are original
studies of well-known diseases, and others deal
with subjects which have been hitherto slighted
in medical literature or which are almost un-
known to it.

I desire to express my thanks for very valuable
aid to my colleague Dr. Whaeton Sinkler, to
Professor Horatio C. Wood, to Dr. Louis Starr,
and especially to Dr. Morris J. Lewis.



CONTENTS.



LECTUEE I.

THE PARALYSES OE HYSTERIA.

PAGE

Paraplegia — Hemiplegia — Bilateral hemiplegia . . .13

LECTUEE II.

HYSTERICAL MOTOR ATAXIA — HYSTERICAL PARESIS.

Briquet's hysterical ataxia — New forms of hysterical ataxia —
Forms of paresis ......... 39

LECTUEE III.

MIMICRY OE DISEASE.

Causes of mimicry — The hysterical state — General nervous-
ness — General failure of health — Psychic peculiarities —
Natural mental and moral conditions favoring mimicry of
disease — Imitative vomiting — Imitative palsj' — Mimicry of
pain — Imitative epilepsy — Imitative meningitis — Epidemic
of rhythmic chorea ........ 55

LECTUEE IV.

MIMICRY OF DISEASE,

Hysteria in childhood — Simulated vomiting — Simulation of
hip-joint disease — Autobiographical confessions . . .81



X CONTENTS.

LECTUEE Y.

PASE

UNUSUAL FORMS OF SPASMODIC AFFECTIONS IN WOMEN.

Rotatory spasms — Functional spasms — Strychnic spasms —
Spasms on change of position — Local spasms simulating
tumors — In the pectoral muscles — In the walls of the ab-
domen — In the gastrocnemius — Hysterical athetosis. . 96

LECTURE VI.

TREMOR.

Hysterical tremor — Nervous tremor with organic disease of
the spine — Alcoholic tremor in nervous women . . .114

LECTURE VII.

CHRONIC SPASMS.

Chronic spasm with simulation of local injury of ulnar nerve
— Chronic spasm of leg — Contracture of leg muscles —
— Treatment of hysterical contractions — Section of tendons
— Simulated contractions — Simulation of contractions and
of disease of ulnar nerve — Chronic spasmodic ptosis . . 123

LECTURE VIII.

CHOREA OF CHILDHOOD.

The relations of the chorea of childhood — To season — To
climate — To locality — To race — Forms of chorea . . 137

LECTURE IX.

HABIT CHOREA.

Definition— Cases of habit chorea— Relatlo to chorea of
childhood — Treatment 1-^6



' CONTENTS. XI

LECTUKE X.

PAGE

DISORDERS OF SLEEP IN NERVOUS OR HYSTERICAL PERSONS.

Sensory shocks — Emotional shocks — Irregular motor dis-
charges — Nocturnal functional hemiplegia — Respiratory
failures in sleep ......... 163

LECTURE XI.

VASO-MOTOR AND RESPIRATORY DISORDERS IN THE NERTOUS OR

HYSTERICAL.

Pulse in hysteria — Agitation of heart followed by apparent
death — Eccentricities of pulse in the hysterical — Palpita-
tion of heart with flushing of face — Palpitation of heart
with pallor of face — Surface ischsemia — Vaso-motor par-
alysis in the limbs or the face — Extreme vaso-motor
paralysis of the whole vascular system of the abdominal
cavity — Respiratory peculiarities of hysteria — Case of rapid
respiration in man from wound ...... 184

LECTURE XIL

HYSTERICAL APHONIA.

Paralysis of laryngeal muscles — Failure of coordination in
the various organs which combine to produce speech . . 208

LECTURE XIII.

HYSTERICAL JOINTS.

Typical case — Hysterical knee with plastic infiltration of con-
nective tissues outside of the capsule 218



Xll CONTENTS.



LECTURE XIV.

PAGE

HYSTERIA AND ORGANIC DISEASE OF THE SPINE.

Old cases of hysteria — Unusual case with spinal disease . 227



LECTURE XY.

GASTRO-INTESTINAL DISORDERS OF HYSTERIA.

Comparative rarity of hystero-epilepsies in America —
Difficulty of feeding hysterical women — Troubles as to
mastication — Eorms of dysphagia — Hysterical anorexia —
Hysterical vomiting — Hysterical fasting .... 238

LECTURE XYI.

THE RECTUM AND DEFECATION IN HYSTERIA.

Irritable rectum — The paretic rectum — Anaesthesia of rectum
— Incoordination in defecation — Painful rectum — Anal
spasm . .... . . . . . • • 252

LECTURE XVII.

THE TREATMENT OF OBSTINATE CASES OF NERVOUS EXHAUS-
TION AND' HYSTERIA BY SECLUSION, REST, MASSAGE, ELEC-
TRICITY AND FULL FEEDING.

Character of cases needing this treatment — Seclusion —
Nurses — Uterine disease — Ovarian disorders — Seclusion —
Rest — Massage — Electricity — Mode of feeding . . .265



DISEASES



OF THB



NERVOUS SYSTEM,

ESPECIALLY IN WOMEN.



LECTURE I.

THE PARALYSES OF HYSTERIA.

The case to which I drew your attention at mj
last clinic is here again, a girl, rather wanting in the
signs of sexual ripeness, although sixteen years old.
You will recall the fact that she lost the use of the
right arm hecause of having been alarmed. The
scare brought on what every woman knows as an
attack of hysterics — our ancestors called it the
vapors. The girl cried and laughed by turns, and
then had a slight fit, on coming out of which she
could no longer lift her right arm, or rather she
could lift it but a few inches. On finding this to be
the case, she grew much concerned, and by and by
could not lift it at all, the idea that it could not be
raised helping, as is apt to be the case, to make the
trouble worse. There seems to have been no deceit,
but perhaps the first feebleness may have been slight,
and the power of her belief in her want of force



14 DISEASES OF THE NERVOUS SYSTEM.

great, and this is rather the more likely since, as you
saw, I raised the arm and said, " Now you can keep
it up," which she did. You see that it seems again
palsied. A new order restores it, and she lifts it
without much effort, having won a belief in my
being able to aid her. I send her away with a
lightly uttered word or two as to the use of the hot
iron, if she again loses power. The warning may
answer, or may not. We had a case very like this
two years ago. I believe it got well.

We see here among the ill-fed, needy, and wor-
ried, a good many cases of hysterical loss of power,
and I meet a yet larger number among women of
the upper classes, in whom the disease is caused by
unhappy love affairs, losses of money, and the daily
fret and wearisomeness of lives which, passing out
of maidenhood, lack those distinct occupations and
aims which, in the lives of men, are like the steady-
ing influence of the fly-wheel in an engine.

A yet more common cause of hysterical disorder
is to be met with among the young persons who
frequent the colleges for women. Every year brings
me a fair contingent of patients from these schools;
and I have asked myself over and over why it is that
these places produce so much disease which ought
to be avoidable. As our society is constituted, it is
clear that women must have opened to them the
higher grades of instruction ; and yet something
must clearly be done to avoid the penalties which
hard study, class competitions, and the emotional
stimulus women bring to their work, are apt to
produce.



PAEALYSES OF HYSTEEIA. 15

Something might be done by a careful medical
examination of the fitness of girls entering colleges.
Their power to work during and just after men-
struation should be inquired into, and their early
months of college work should be carefully watched.
Above all, their eyes ought to be examined, because
numerous women become ill from the strain of brain-
work done with imperfect vision. Moreover, these
inspections should be repeated at reasonable intervals.

Let me admit in passing that, at Yassar and some
other schools, the machinery and organization for the
care of the physical and mental health of students
exists ; but it does not seem to work satisfactorily.
The reason is only too clear. The general sense —
shall I say the prejudices — of such groups of women
is opposed to conceding the belief held by physi-
cians that there are in the physiological life of
women disqualifications for continuous labor of mind.
Public sentiment is in women's colleges against this
belief, and acts as a constant goad for women at
times unfit to use their brains. If ever the horrible
system of coeducation of the sexes becomes more
general, this difficulty will, of course, be mischiev-
ously emphasized by the modest dislike of the weaker
girls to exhibit, at intervals, signs of failure, or to
excuse themselves from tasks which they cannot
competently pursue alongside of the male, who is
not weighted by the occasional need to plead any
form of recurrent disability.

It is my present wish to speak of some of the
many kinds of hysterical paralysis, and to dwell far
more freely on methods of treatment than upon



16 DISEASES OF THE NEKVOUS SYSTEM.

minute details in the natural history of these dis-
orders. I do this chiefly because as regards treat-
ment I hold very positive opinions, and because
these opinions have, I believe, been amply justified
by happy results, some of which are familiar enough
to those who have followed my practice.

The group of instances of lessened power which
I shall here discuss will include the usual forms of
hysteric paraplegia and hemiplegia, and that which
I shall call double hemiplegia. I shall not attempt
to cover the whole range of hystero-palsies, but seek
chiefly so to define a certain number as to allow me
to speak of their treatment. I shall also describe
four forms of seeming loss of power, only one of
which is essentially hysterical in nature, and not
found elsewhere with the same features. I allude
to hysterical motor ataxia.

The others are palsy from the rule of an idea,
general paresis, and consciously mimicked palsy.

All three of these may be and are seen outside of
hysteria, but they find in it a fertile soil, and are
none the easier to treat when they are masking in
this disguise.

One of the chief troubles in clearly knowing and
in dealino; with all of these forms of disease is due to
the fact that in most cases, and to some extent, they
may exist in union. The case of palsy may be partly
real, partly pure weakness, partly loss of power from
want of belief in being able to move; or conscious
mimicry may be added to palsy or to the forbidding
influence of a regnant idea, or to the true hysteric
palsy may be joined ataxy of motion. For such vex-



PARALYSES OF HYSTERIA. 17

ing marriages of disorders, and for their offspring of
doubt, we must be ready and watchful. They make
the true limits of hysteric lack of power hard to de-
fine, hard to treat, full of surprises, and unfailing in
interest and variety. Take this for an instance : You
have a case of extreme hysteric paresis to treat. As
a rule, it is readily cured. You predict a clear and
happy future. As time wears on the mere weakness
is gone, the limbs are plump again, the cheek red,
and then you may find, if you have not been careful,
as I have found, that hidden in the mere weakness
there is a distinct amount of motor palsy — a mild,
one-sided loss of power — a true hysteric palsy, and
not at all easy to cure. I shall pick for you, out of
my note-books, cases of each of the forms of disease
I have just spoken of, and shall try to make plain to
you how I treat them. There were once no cases so
much dreaded by me. There are now none to which
I go with so much pleasure, I am sure that I treat
them to-day with a success I could not once have
gained, and I think that what success I have had has
been due to more exact ideas as to what is needed,
and that unflinching purpose and action which grow
out of distinct views.

Let us take first a case of paraplegia — less common
than hemiplegia and more difficult to relieve. The
example I shall quote for you is the more interesting
because of its having ended in death.

Mrs. C, set. 36, a strong woman, and in all ways
well, lost by sudden death a child and her husband.
Thus having cast on her the care of a large estate,
loaded with many burdens, she began to show excess

2*



18 DISEASES OF THE NERVOUS SYSTEM.

of anxiety as to her affairs, and from being sweet
of temper became abrupt and full of unreasonable
doubt as to her advisers. The worry brought with
it speedy loss of blood globules, and as she was a
woman who flowed very freely each month, all these
causes together began to tell. This is the kind of
thing we see much of in medicine. The books say
this, that, or the other causes hysteria. In practice
it is usual to find two or three causes — acting to
assist one another. This woman was quite ready for
an outbreak of some form of nerve trouble, when of
a sudden she met the final blow in the form of a
telegram. The news it bore was neither good nor
ill, but by evil luck the writing looked like that of
her dead husband, and she began to laugh with that
strange want of appropriateness in emotional expres-
sion so common in the nervous. Awaking next day
her legs seemed heavy, which caused her great alarm.
At once, as she told me, the fear of palsy arose in
her mind, and haunted her the more as, day by day,
the feebleness grew worse. She was in Germany
when taken ill, and seems to have been looked upon
as suffering from an organic malady, for she was
treated with nitrate of silver and the hot iron. Then
as she failed to get relief anywhere, she was sent
from one spa to another with a skill which as yet we
are fortunately far from being able to reach.

St. Moritz, Schwalbach, Vichy, Loueche, and
springs of less note, had each their turn, after the
European fashion, until, in despair, she was carried
back to America, where I saw her often and until
the close of her life.



PAEALYSES OF HYSTERIA. 19

This was what I found : A woman of 36, height
5 feet 2 inches, weight 170 lbs., flabby, and thin-
blooded, with healthy heart, lungs, and kidneys. On
the left side of the vagina was felt a tumor about the
size of a walnut. It was very tender, and firm pres-
sure on it gave rise to nausea and distress down the
left leg. I had no doubt that this growth w^as a dis-
placed ovary, but despite this change of place, the
left iliac fossa, both the skin and the parts reached
by deeper pressure, was tender to touch. Was it
ovarian tenderness ? Hardly, in this case. I have
been told by Dr. Goodell that he has seen this same
sensitiveness in other instances where the ovary had
been displaced, and probably too much has been and
is made of this symptom. The tenderness in Mrs.
C.'s case was isolated, as is not unusual, and all about
it up to the waist and down to the feet the bod}^ was
without sense of touch or pain, or of heat and cold.
In tracing this defect upwards it was found to cover
the left breast, but this was so to-day, and then to-
morrow it was less, the upper limit ranging from the
navel to the left armpit.

Motor power was failing when I first saw her, but
this had been the case before, and had been followed
by a change for the better.

The plan pursued in treating the case was one to
which I groped my way a few years ago. My patient
was very thin-blooded, and yet very fat. Such cases,
for some reason not clear to me, are more hard to
redden than are those of thin people in like states of
blood. But if you can safely cause these persons to
lose flesh, as they are helped to remake it, you may



20 DISEASES OF THE NERVOUS SYSTEM.

sometimes redden them with ease, and to raise the
number of blood globules to the normal is usually to
lift a woman above that low level of health, which
is one, at least, of the factors of hysteria.

Mrs. C. was, when first seen by me, sitting up most
of the day, and sewing, writing, and the like, when
not too nervous. I put her in bed, and employing
as a diet milk alone, mixed with a little rice-water or
barley-water, I began to lessen the amount given,
until, using less than a quart a day, her weight fell
off at the rate of about a quarter to a half pound a
day. When she showed signs of weakness I added
beef soup to the diet for a day or two, and thus in
one month brought down her weight some twenty-
four pounds. This could not with safety have been
so quickly done had not the patient have been kept
in bed. Then the milk was by degrees increased.
Raw beef and vegetables were added, malt extract
was used before meals, a little red wine or champagne
was allowed, and iron was given freely, the feeding
being frequent. When I made the increase in diet
I began to arouse sensation by the use of the wire
brush and induction currents.

E'ow in common palsies, or in those from nerve
wounds, feeling is apt to come back first, motion
last; but in hysteric palsies, as I think, the gain in
active motion may go on, and even reach a useful
amount while yet the lack of feeling rests as it was
when the treatment began. Just this change took
place in Mrs. C. : She grew brighter, and more
happy, gained in color and flesh, and began to move
her legs. In a month after she reached full diet she



PAKALYSES OF HYSTEEIA. 21

could walk with some trouble, and about this time
the sense of touch showed signs of betterment, but
the power to feel pain was unchanged, and, in fact,
was never complete in the left leg.

I^ext began a plan of steady, urgent calls upon her
for increase of the use of her limbs, so that before
long she was able to walk out of doors. At this point
I fear there was a mistake made in the treatment.
Thinking the battle won I pushed her too hard, and
one day after walking much further than usual she
felt an excess of fatigue. Returning home she gave
out of a sudden, and the morning after was again
hardly able to stir either leg. I may pause here to
repeat as to this matter a warning I have often given.
It is to urge on you the utmost care as to allowing a
hysterical patient on the way to health — I mean, of
course, one who has lost power — to do more each
day than fulfil the ordered task of that day. Most
cases of hystero-palsies are easily tired, and it is
almost sure to be the case that they cannot make a
long effort without showing the effect in some way;
moreover the mental results of extreme tire are to be
feared, because any positive, real sensation is apt to
become the peg, so to speak, on which the patient
may hang the complement of a larger and less real
sensation.

More slowly this time Mrs. C. got back some con-
trol over her movements, but at a certain point the
gain ceased, and we made no further progress, nor
did this surprise me. Hysterical paraplegia is, as I
have said, more hard to cure than any other hys-
terical trouble except, perhaps, multiple contractures,



22 DISEASES OF THE NEEVOUS SYSTEM.

and I felt that I had done well to win what I had
won.

About six months later this lady died after a brief
illness, which seemed to me more like a sudden and
complete palsy of the pneumogastric nerves than
anything else. 'No examination post mortem w^as
allowed. I have seen three deaths in hysteria; all
were abrupt, and two were due to acute congestion
of the kidneys.

The following case resulted more happily : The
patient, a woman get. 18 years, had been in good
health. Her paraplegia w^as caused by seeing her
father seriously injured by a fall from a horse. She
became feeble, ceased to eat sufficiently, and in a
week was unable to lift hand or foot. She was
brought to me six months later, and was then a rosy
girl of eighteen, not wasted, but presenting a singular
flabbiness of the muscular masses. The loss of power
in the legs and feet was so complete that, except in
the left foot, no motion could be seen. The hands
were so feeble as to be useless, although all the
fingers could be moved. Even the neck was too
weak to sustain the head. I had never seen the loss
of power in hysteria so complete. That of sensation
was not less so. The face was on both sides defective
in power to feel pain or touch, or change of tem-
perature, yet smell, taste, and hearing were as in
health. I expected to observe some notable func-
tional disturbance in the eyes, and therefore asked
Dr. Wm. Thomson to see her. The most elaborate
examination by this expert ophthalmologist failed to
show the existence of even the slightest defect of



PARALYSES OF HYSTERIA. 23

color-sense, or, in fact, anything except hyperme-
tropic astigmatism. Below the face there was no
ability to feel pain. The sense of touch was lessened
in acuteness, but not lost. The power to localize an
impression was impaired, and the sense of tempera-
tures lost. I should have said that beneath the skin
there was some feeling. On applying to the nipple
the bare metal poles of the secondary current of an
induction coil — a severe test — no signal of pain ap-
peared ; but, when two needles were carried through
the skin, and a strong current passed between them,
some pain was felt. Over the dorsal and cervical
spine — that is, from the third cervical to the tenth
dorsal spine — was a space about an inch wide in
which pin-pricks could be readily felt. Elsewhere the
needles used caused no more expression of pain than
if the woman's flesh had been a pincushion, and no
bleeding followed their use. As there w^as constant
regurgitation of strongly acidulated food after each
of the large meals she took, she was placed on the
exclusive use of milk containing two grains of bi-
carbonate of soda to the ounce. This, with massage
and electricity, and such training as I shall describe
at another place, triumphed after two months, and
she became able to eat, sleep, and walk, much as
others do. l^evertheless, the analgesia remained
nearly the same in the legs as at first, although it
disappeared above the waist almost entirely. The
sense of touch was not more improved than that of
pain, and this was as stated when she had become
well enough to walk two miles. She seems uncon-
scious of this continued defect, and my previous



24 DISEASES OF THE NERVOUS SYSTEM.

experience teaches me to hope that by degrees the
analgesia will disappear. In fact, the most useful
lesson we can draw from this and other like cases is
the fact that full volitional control may return while
the sense of touch or of pain remains greatly im-
paired. Once set the patient usefully afoot, and we
shall do well to cease to call attention to the con-
tinuance of the sensory failure. Secure to such cases
a quiet, unemotional life, and with the renewal of
healthy nutritive functions, the sensory failures will
in turn cease to exist.^

Of that more common type, the palsies of one side
of the body, you have seen a number. In this
country, at least, they are more frequent than the
paraplegias; less hard to cure, but quite lasting
enough to make you cautious as to what you predict
about their future. Where they occur in the feeble
and thin-blooded, who have by degrees grown emo-


1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Online LibraryS. Weir (Silas Weir) MitchellLectures on diseases of the nervous system, especially in women → online text (page 1 of 21)